CAMP HM SMITH, Hawaii — Human error was the primary cause of two separate fuel spills at a Navy storage facility in Hawaii in 2021 that contaminated the drinking water of thousands of residents of military communities, according to a investigation report released Thursday.
“But human error is not the whole story,” concludes the investigation ordered by Admiral Samuel Paparo, the chief of the American Pacific Fleet, just days after the inhabitants began to settle in late November. complain about oil contaminated water.
“The investigation further revealed several preventable contributing factors, including a culture of non-compliance with procedures; material deficiencies; poor training and supervision; ineffective command and control; lack of ownership regarding operational security; unacceptable immediate response actions, including a lack of timely, accurate and complete reporting; and a fundamentally flawed investigation process regarding “the first of two spills on May 6 and November 20.”
Jet fuel from spills at the Red Hill Bulk Fuel Storage Facility, a massive World War II-era underground tank farm, has seeped into one of three wells the Navy uses in its system water supply for communities on and near Joint Base Pearl Harbor-Hickam.
The contamination displaced thousands of residents for several months from the end of November. The contaminated well remains closed as work continues to clear it of oil.
Defense Secretary Lloyd Austin announced on March 7 that the storage facility would be permanently closed.
The multi-phase plan to drain and shut down the facility will not be completed until late 2024, Meredith Berger, deputy secretary of the Navy for energy, facilities and the environment, told a panel discussion. media Thursday at Camp HM Smith in Honolulu.
The roundtable also included Paparo and Adm. John Aquilino, Commander of US Indo-Pacific Command.
“Through everything and in every action, we will operate at the speed of safety,” Berger said virtually from the Pentagon. The Navy will continue to refine its closure efforts and will “seek opportunities to accelerate our schedule based on information, but not at the expense of safety,” she said.
Broken pipe joints
The investigation, which was completed in January, and an additional part which ended in April detail the missteps of the two spills that led directly to well contamination.
On May 6, 2021, operators at the storage facility “improperly performed a fuel transfer procedure,” which caused two pipe joints to rupture, the report said.
About 21,000 gallons of jet fuel spilled into a room designed to automatically seal in the event of a leak. According to the investigation, the leak activated sump pumps which pushed fuel into a long fire extinguishing hold-up line, but operators were unaware of the pump action.
“The decrease in tank inventory of nearly 20,000 gallons of fuel coinciding with the May 6, 2021 spill should have fostered a more critical and thorough investigation” by supervisors, the report said.
A “prompt” Naval Supply Systems Command investigation “failed to identify the root causes” of the spill and recommended no “meaningful corrective action”, the newly released investigation said.
Between May and November, the weight of the missing fuel now lodged in the plastic retention line caused it to slowly sag.
“The fire suppression system is poorly designed and has not been properly maintained,” the report said.
Workers move through the lower access tunnel using a trolley on the railroad tracks, and over time the overhead retention line has subsided enough that the trolley brushed a valve and cracked the pipe .
On November 20, the trolley operator discovered that the hose was leaking with “the equivalent of four safety showers running full blast at the same time”, according to the investigation report.
About 20,000 gallons of fuel were recovered, but about 5,000 more gallons seeped through the cracks in the concrete, then moved relatively quickly through the porous basalt bedrock and into the shaft.
“Had the leaders at the scene more critically questioned the potential for an environmental release, they would have acted more decisively to stop the source of the spill and demanded more resources to manage it,” says The report.
“The lack of critical thinking, intellectual rigor and self-assessment by key leaders at decisive moments exemplifies a culture of complacency and demonstrates a lack of professionalism demanded by the high-consequence nature of fuel operations,” concludes the investigation.
The investigative report released Thursday redacts all names of those operating the system or involved in responding to the spills.
Asked about the number of people who have been disciplined, reassigned or fired as a result of the water crisis, Paparo said that “there are a number of people who are no longer in their assigned roles.”
“Some of this information remains legally privileged,” he said.
The commander of U.S. Fleet Force Command “will administer justice to those identified as potentially having poor performance or dereliction of duty,” Paparo said.
“This investigation will inform that process as well as an additional evidentiary legal process in order to administer that justice,” he said.